A few weeks after the supreme court’s 24 June decision to overturn the nationwide abortion rights established by Roe v Wade, the pharmacy chain Walgreens sent Annie England Noblin a message, informing her that her monthly prescription of methotrexate was held up.
Noblin, a 40-year-old college instructor in rural Missouri, never had trouble getting her monthly prescription of methotrexate for her rheumatoid arthritis. So she went to her local Walgreens to figure out why, standing in line with other customers as she waited for an explanation.
When it was finally her turn, a pharmacist informed Noblin – in front of the other customers behind her – that she could not release the medication until she received confirmation from Noblin’s doctor that Noblin would not use it to have an abortion.
Since the supreme court’s elimination of federal abortion rights, many states have been enacting laws which highly restrict access to abortion, affecting not only pregnant women but also other patients as well as healthcare providers.
As a result, many pharmacies and physicians have been forced to deny and delay patients’ access to essential medications – such as methotrexate – that can be used to help induce an abortion.
Noblin is one of the 5 million methotrexate users across the US and one of the country’s many autoimmune patients. Although she was eventually given her prescription, Noblin and other patients are now forced to grapple both with a monthly invasion of privacy at pharmacies that ask them about their reproductive choices as well as the possibility of being wholly denied the medication in the future due to restrictive laws.
For 60 years, methotrexate has been considered a cheap, standard treatment for nearly 60% of rheumatoid arthritis patients. It is also widely used to treat other autoimmune diseases, including Crohn’s disease, lupus and psoriasis. And, because it inhibits certain cellular functions, it has been used to treat a variety of cancers including leukemia, breast cancer, lung cancer and lymphoma.
But methotrexate also treats ectopic pregnancies, in which a fertilized egg implants outside the uterus. Although rare, with only about 100,000 occurring annually, ectopic pregnancies are fatal for fetuses and can severely jeopardize mothers’ health. Therefore, the only treatment is abortion, and methotrexate commonly is combined with other medicine to perform the procedure.
Methotrexate’s versatility prompted the World Health Organization to classify it as an “essential medicine”. Yet Roe v Wade’s reversal has significantly stunted access to the drug – even for patients who are not pregnant and simply require the drug to treat other conditions.
Numerous health organizations have confirmed reports of methotrexate being denied to women since the federal abortion rights were eliminated.
Calling the drug “an important part” of caring for the illness it is dedicated to fighting, the Lupus Foundation of America said: “We are aware of reports that some people are having difficulty accessing methotrexate in the wake of the supreme court’s ruling [in June].”
Similarly, the American College of Rheumatology said that it was aware of the “emerging concerns surrounding access to needed treatments such as #MTX [methotrexate] after the recent decision” from the supreme court in the Dobbs case that led to Roe v Wade’s reversal.
In Missouri, abortion is completely banned with limited exceptions for saving the pregnant person’s life or to prevent serious risk to that person’s physical health. As a result, for someone like Noblin, being banned from getting access in Missouri to her monthly doses of methotrexate – even if temporarily – was and is still quite damaging.
Methotrexate helps Noblin and others alleviate pain as well as swelling in their hands and shoulder joints that occasionally becomes so excruciating that it hinders their ability to get dressed or drive to work.
“If I weren’t taking it,” Noblin told the Guardian, “I don’t know how I would be able to function.”
After her pharmacy got confirmation from her doctor that she was not going to be using the drug to induce an abortion, Noblin was finally able to get her prescription for July. In August, Noblin went into the pharmacy again, expecting the process to be smoother this time around. However, to her surprise, she was required to consult with a pharmacist before getting the medication and confirm that she was not pregnant and didn’t intend to become pregnant while taking the medication.
Noblin told the pharmacist it was not their business. The pharmacist then told Noblin that she would not be able to get her medication if she did not answer the question.
“I’m going to have to answer [that] every single month before they will even consider giving me the medication,” Noblin said.
Additionally, another problem that Noblin and many others face is potentially being forced to spend $14,000 a month without insurance for Humira as a brand-name alternative. And they are worried about prosecution by their states.
Noblin said she is on birth control but frets to think if she still gets pregnant.
In that case she said she would get an abortion in Illinois, which has protected abortion rights. But would she be exposed to prosecution, accused of lying because she would have told a pharmacist she didn’t intend to get pregnant?
“It feels like I don’t have any control over my own body,” Noblin said. “My body belongs to Missouri.”
Jennifer Crow, a 48-year-old from Tennessee, faced similar issues after the supreme court eliminated federal abortion protections. On 1 July, Crow, who has inflammatory arthritis, received an automated call from her CVS pharmacy, informing her that her refill was declined.
The call came in during Friday evening on a holiday weekend. As a result, Crow was left without her weekly dose of methotrexate.
Before she started methotrexate, Crow’s joints would become too stiff and sore for her to move without pain in the mornings, limiting her mobility significantly.
“Methotrexate gave me back my independence,” she told the Guardian. “I knew without it, I’d be right back to limited mobility and lots of pain.”
Four days later, the pain and stiffness started to return. She also began panicking, unsure if she would ever be able to get her medication because she and her Georgia-based medical providers were both in states that implemented abortion bans after the Dobbs decision.
She couldn’t understand why she was in that position, given that she’d had a hysterectomy years earlier. Eventually, Crow found out that CVS refused her refill because the chain had asked pharmacists to decline filling methotrexate prescriptions unless they indicated a diagnosis unrelated to an abortion, a practice Crow finds “invasive and unnecessary”.
Crow, like Noblin, eventually got her prescription refilled. But since her treatment’s disruption she has struggled with increased pain and decreased mobility.
“The Dobbs decision has many unintended consequences, and as a middle-aged woman without a uterus, I didn’t think it would affect my care,” she said.
Complicating matters: methotrexate is not the only essential medication that many are now struggling to access, despite the US health and human services department’s guidance on laws prohibiting pharmacies from rejecting patients with prescriptions for medications that may end a pregnancy.
People on misoprostol – which prevents stomach ulcers for those who take aspirin, ibuprofen or naproxen – are also facing access hurdles because the drug can also be combined with other medication to induce abortion, said the Global Healthy Living Foundation’s chief legal officer, Steven Newmark. Such disruptions not only can lead to “serious health consequences”, but they violate patients’ treatment preferences, Newmark added.
Nonetheless, methotrexate vividly illustrates the uncertainty created by Roe’s reversal. Texas lawmakers have made it a felony to dispense methotrexate there to someone who is past seven weeks pregnant and uses the medication to terminate a pregnancy.
There have been reports from doctors that some pharmacies are refusing to carry methotrexate and other certain essential medication entirely. And some physicians have refused to prescribe those medications to patients who may become pregnant, citing concerns about prosecution.
In a joint statement by multiple pharmacy organizations across the country, pharmacists and healthcare providers expressed concern about “state laws that limit patients’ access to medically necessary medications and impede physicians and pharmacists from using their professional judgment”.
The statement went on to call for clear guidance from state boards of medicine and pharmacy, agencies and other policymakers.
To Rachel Rebouché, an expert in reproductive health law and dean of Temple University’s law school, the largest problem is clear.
“The biggest issue is the confusion,” Rebouché said.